An Infusion of Ketamine in the Emergency Department Might Reduce Acute Suicidality

From NEJM’s Journal Club:

Subanesthetic doses of intravenously infused ketamine can reduce depressive symptoms and have been reported to reduce suicidal ideation. To ascertain the strength of these findings, investigators performed a systematic review and meta-analysis of 10 studies that administered a single dose of intravenous ketamine versus saline or midazolam (N=167). Patients had treatment-resistant unipolar or bipolar depression; one study included post-traumatic stress disorder.

The researchers used patient-level data, examined measures targeting suicidal ideation, and controlled for age, sex, treatment setting, diagnosis, concomitant psychiatric medications, and depressive symptoms. Ketamine compared with controls reduced suicidal ideation as early as day 1 and up to day 7, with moderate-to-large effect sizes, by both clinician rating and self-report. The proportions of patients free of clinician-rated suicidal ideation were 55% at 24 hours and 60% at 1 week (numbers needed to treat, 3.1–4.0); benefits persisted at 1 week in 86%. Although suicidal ideation and depressive symptom severity correlated highly, the benefit of ketamine for suicidal ideation remained significant after changes in depression severity were controlled for.

Community and Provider Resources to Address Violence and Abuse in Rural America

From RAC Monitor:

Every day, mental, physical, and emotional bruises and scars are inflicted on victims throughout the United States. Violence in rural America happens all too frequently across the age and socioeconomic spectrums, without enough voices, resources, and solutions being presented. For that reason, every second Wednesday of October is now marked by Health Cares About Domestic Violence (HCADV) Day.

This year’s HCADV fell on Wednesday, Oct. 11, but the resources shared and opportunities presented can be used 365 days a year. Sponsored by Futures Without Violence, the awareness-raising event aims to reach various members of the healthcare industry, including rural providers and advocacy communities, in order to offer universal education about the vital importance of education to promote healthy relationships and address the health impact of abuse, which can be classified accordingly:

  • Domestic violence, also known as intimate partner violence (IPV)
  • Sex crimes, including rape, assault, and abuse
  • Abuse of vulnerable populations, such as the elderly and people with disabilities
  • Bullying, harassment, and stalking
  • Neglect
  • Child abuse
  • Assault
  • Homicide

Want to Reduce Avoidable Emergency Department Visits by High-Utilizers?

From NEJM’s Journal Watch:

Health systems are focused on developing alternatives to the emergency department (ED) for patients with non-acute and chronic health concerns. Such approaches may involve increased access to primary care, but they often fail without community engagement or care coordination to overcome societal barriers to care. Researchers evaluated outcomes for patients enrolled in a federally funded multidisciplinary program that enrolled high-utilizers (adults with 2 or more ED visits within the prior 6 months) and provided social, medical, and behavioral care, either in the home or at a homeless shelter.

Propensity score matching was used to compare outcomes for 406 patients enrolled in the program and 3396 controls. In the 6-month period after enrollment, the intervention group had 28% fewer ED visits, 16% fewer hospitalizations, and 114% more primary care visits than the control group. These group difference were even greater in a subanalysis of patients with mental health disorders and at 1 year.

Feds Increase EMTALA Penalties against Physicians and Hospitals

From Emergency Physicians Monthly (hat tip: Dr. Menadue):

The Office of Inspector General recently doubled the potential monetary penalty for violations of EMTALA, added a new physician decision-making scenario subject to the penalty, and modified the factors considered in determining the amount of the penalty.

6 in 10 doctors report abusive remarks from patients, and many get little help coping with the wounds

From STAT:

Most doctors have absorbed racist, sexist, and other bigoted verbal remarks from patients under their care, according to a new national survey. And in interviews, physicians say these ugly incidents, while not frequent, can leave lasting scars.

“GOP Lawmaker Says Emergency Rooms Should Be Able To Turn People Away”

From the Huffington Post:

Nobody thinks EMTALA is perfect and non-partisan organizations, including the Institute of Medicine, have long called for revising some of the law’s regulations as part of a broader strategy to ease emergency room overcrowding. And although conservatives have been among the most critical of the law, even the Heritage Foundation admits that “the outright repeal of EMTALA is highly unlikely,” and it’s not something you hear talked about much in health care debates.

When Todd asked Black whether she would get rid of the law, she replied, “I would get rid of a law that says that you ― you are not allowed, as a health care professional, to make that decision about whether someone can be appropriately treated the next day, or at a walk-in clinic, or at their doctor.”

New study: nearly half of US medical care comes from emergency rooms

Press Release:

Nearly half of all US medical care is delivered by emergency departments, according to a new study by researchers at the University of Maryland School of Medicine (UMSOM). And in recent years, the percentage of care delivered by emergency departments has grown. The paper highlights the major role played by emergency care in health care in the U.S.

“I was stunned by the results. This really helps us better understand health care in this country. This research underscores the fact that emergency departments are critical to our nation’s healthcare delivery system.” said David Marcozzi, an associate professor in the UMSOM Department of Emergency Medicine, and co-director of the UMSOM Program in Health Disparities and Population Health. “Patients seek care in emergency departments for many reasons. The data might suggest that emergency care provides the type of care that individuals actually want or need, 24 hours a day.”

Although he now focuses on population health, Dr. Marcozzi is an emergency room doctor himself, and works one or two days a week in the University of Maryland Medical Center emergency department, treating patients.

This is the first study to quantify the contribution of emergency department care to overall U.S. health care. The paper appears in the latest issue of International Journal for Health Services.

For this study, Dr. Marcozzi and his colleagues examined publicly available data from several national healthcare databases, which covered all 50 states and the District of Columbia. They studied the period between 1996 and 2010.

For 2010, the most recent year studied, the study found that there were nearly 130 million emergency department visits, compared with almost 101 million outpatient visits and nearly 39 million inpatient visits. Inpatient visits typically involve a hospital stay, but are planned ahead, as opposed to emergency department visits, which are generally at least somewhat unexpected.

Over the 14-year period of the study, more than 3.5 billion health care contacts – emergency department visits, outpatient visits, and hospital admissions took place. Over that time, emergency care visits increased by nearly 44 percent. Outpatient visits accounted for nearly 38 percent of contacts. Inpatient care accounted for almost 15 percent of visits.

Certain groups were significantly more likely to use the emergency department as their method of healthcare. African-American patients were significantly more likely to have emergency department visits than patients in other racial groups; patients in the “other” insurance category, which includes those without any type of insurance, were significantly more likely to have emergency department visits than any other group. And patients living in the South were significantly more likely to have emergency department visits than patients living in other areas of the country.

African-American patients used emergency departments at a higher rate than other groups. In 2010, this group used the emergency department almost 54 percent of the time. The rate was even higher for urban African-American patients, who used emergency care 59 percent of the time that year. Emergency department use rates in south and west were 54 percent and 56 percent, respectively. In the northeast, use was much lower, 39 percent of all visits.

Certain groups accounted for increasing percentages of overall emergency room use: African-Americans, Medicare and Medicaid beneficiaries, residents of the south and west, and women. Dr. Marcozzi says that these findings point to increasing use by vulnerable populations, which is no surprise since socioeconomic and racial inequality creates barriers to the use health care.

The use of emergency care resources for non-emergency cases has been controversial, since initial emergency care patients often end up being seen for non-emergency medical issues. Some experts argue that emergency departments are covering for deficiencies in inpatient and outpatient resources, and for a lack of effective prevention strategies. This could contribute to the high rate of emergency department use. They argue that emergency room use should be reduced.

Dr. Marcozzi says this is unlikely to happen anytime soon, given the structure of the country’s health care system. He also notes that it may not be the best option. Instead, he says we should work to connect the care delivered in emergency departments with care delivered by the rest of the healthcare system.

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The paper was co-authored by researchers at other academic institutions, including Brendan Carr, a professor of emergency medicine and associate dean at Thomas Jefferson University.